Technical Complications and Prosthesis Survival Rates with

Implant-Supported Fixed Complete Dental Prostheses: A

Retrospective Study with 1- to 12-Year Follow-Up
Panos Papaspyridakos, DDS, MS, PhD ,1,2 Thaisa Barizan Bordin, DDS, MS, PhD,3,4
Yong-Jeong Kim, DMD, MS, Khaled El-Rafie, DMD,1 Sarah E. Pagni, PhD,5 Zuhair S. Natto, DDS, MS,
1

DrPH,6,7 Eduardo Rolim Teixeira, DDS, MS, PhD,4 Konstantinos Chochlidakis, DDS, MS,2 &
Hans-Peter Weber, DMD, Dr.Med.Dent.3
1
Division of Postgraduate Prosthodontics, Tufts University School of Dental Medicine, Boston, MA, USA
2
Department of Prosthodontics, University of Rochester Eastman Institute for Oral Health, Rochester, NY, USA
3
Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, MA, USA
4
Department of Prosthodontics, Postgraduate Program in Dentistry, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil
5
Department of Public Health and Community Service, Tufts University School of Dental Medicine, Boston, MA, USA
6
Department of Dental Public Health, King Abdulaziz University, Jeddah, Saudi Arabia
7
Department of Periodontology, Tufts University School of Dental Medicine, Boston, MA, USA

Keywords
Technical complications; implant
complications; prosthesis survival; dental
implants; implant fixed complete dental
prostheses; full arch implant prostheses.
Correspondence
Panos Papaspyridakos, Division of
Postgraduate Prosthodontics, Tufts
University School of Dental Medicine, One
Kneeland Street, Boston, 02111 MA, USA.
E-mail: panpapaspyridakos@gmail.com
Funding from the Department of
Prosthodontics at Tufts University School of
Dental Medicine and the Brazilian National
Council for Scientific and Technological
Development.
The authors deny any conflicts of interest in
regards to this study.
Accepted October 7, 2019
doi: 10.1111/jopr.13119
Abstract
Purpose: To report the rate of technical complications and prosthesis survival in a
cohort of edentulous patients treated with implant-supported fixed complete dental
prostheses (IFCDPs) after a mean observation period of at least 1 year.
Materials and Methods: The single-visit examination included clinical and
radiographic assessment, occlusal analysis, photographs and questionnaire assessing
patient satisfaction in a cohort of 52 patients rehabilitated with 71 IFCDPs (supported
by 457 implants). The IFCDPs were assessed for technical complications, number
of implants and cantilever extension, retention type and prosthetic material type.
Comparison was made between ceramic IFCDPs (Group 1) and metal-resin IFCDPs
(Group 2). Kaplan-Meier survival curve analysis was carried out for assessment of
prosthesis survival and was done for both Groups 1 and 2 separately. The Cox propor-
tional hazard model was used for survival analysis, adjusting for a number of potential
confounders, to evaluate the association between prosthesis survival and several risk
factors such as type of opposing occlusion, nightguard use, and presence of bruxism.
Responses to patient satisfaction questions were compared with Fisher’s exact test.
Results: Out of 71 edentulous arches (52 patients) restored with IFCDPs, 6 IFCDPs
had failed, yielding a cumulative prosthesis survival rate of 91.6 % after a mean
observation period of 5.2 years (range: 1-12 years) after definitive prosthesis insertion.
Three IFCDPs were lost due to implant failures after 5.8 to 11 years of functional
loading. Additionally, 3 metal-resin IFCDPs failed due to technical complications.
Minor complications were the most frequent complications observed, namely wear
of the prosthetic material (9.8% annual rate) being the most common, followed by
decementation of cement-retained IFCDPs (2.9%), and loss of the screw access filing
material of the screw-retained IFCDPs (2.7%). The most frequently observed major
complication was fracture of the prosthetic material (1.9% annual rate), followed
by fracture of occlusal screw (0.3%), and fracture of framework (0.3%). The annual
rate of wear of prosthetic material was 7.3% for porcelain IFCDPs (n = 19/55) and
19.4% for metal-resin IFCDPs (n = 13/16), yielding a statistically significant
difference between the 2 groups (p = 0.01).
Conclusions: After a mean exposure time of 5.2 years, 91.6% prosthesis survival rates
were achieved (65 out of 71 IFCDPs). The most frequent minor technical complication
was wear of the prosthetic material with estimated 5-year rate of 49.0%, while the most
frequent major complication was fracture of the prosthetic material with estimated
5-year dental unit-based rate of 9.5%. The cumulative rates for “prosthesis free of
minor complications” at 5- and 10-years were 60.5% (95% CI: 47.2-71.3%) and 8.9%
(95% CI: 2.9-18.0%), respectively. The cumulative rates for “prosthesis free of maj-
or technical complications” at 5- and 10-years were 85.5% (95% CI: 73.0-92.5%) and

Journal of Prosthodontics 29 (2020) 3–11 

C 2019 by the American College of Prosthodontists 3
Technical Complications with Full-Arch Implant Prostheses
30.1% (95% CI: 12.0-50.6%), respectively. Presence of bruxism, and absence of a
nightguard were associated with increased risk for chipping of the prosthetic material
of the IFCDPs.
With substantial clinical and scientific evidence available,
implant-supported fixed prostheses are a reliable treatment
option for the replacement of missing teeth.1-8 While many
longitudinal studies have reported data on implant survival,
data on implant complications are still sparse.9-12 The main
focus of previous longitudinal studies in the 1990s was the
success of osseointegration and the survival of the implants,
while other complications were rarely reported.9,11
With the more recent shift of focus on esthetics and
patient-centered outcomes, more clinical studies started to
include these variables, yet implant complications are still
underreported.6,10-13 Specifically, a systematic review by
Papaspyridakos et al10 revealed that biologic and technical
complications routinely occur with implant-supported fixed
complete dental prostheses (IFCDPs) for edentulous patients.
Hence, the knowledge of incidence, types, and rates of
complications with each treatment modality is necessary.10-13
Biologic and technical complications in implant dentistry
do occur and are time dependent.10,14 Technical complications
after the definitive prosthesis insertion may lead to increased
rates of repair and remakes, and the waste of chair side time and
financial resources, and may even affect the patient’s quality
of life. Few studies have attempted to assess quantitatively the
costs associated with IFCDPs and maintenance.15 From the
financial and effectiveness viewpoint, the patient and dentist
preferences for specific treatment options should ideally rely
on the longitudinal efficacy of the option coupled with the
associated cost and maintenance.10,16,17 From the viewpoint of
outcome assessment, clinical outcomes of implant treatment re-
quire a time span of 5 years or more in order to draw meaningful
conclusions.
However, data specifically related to technical implant com-
plications encountered with IFCDPs for edentulous patients
after an observation period of 5 years are limited.3,6,8,10,15,18-21
To the authors’ knowledge, this is the first study documenting
the technical complication and prosthesis survival rates of full
arch rehabilitation with moderately rough surface implants
and IFCDPs by residents in a postgraduate prosthodontic
clinic under supervision by experienced prosthodontists. The
primary purpose of this retrospective clinical study was to
report the technical complication and prosthesis survival rates
with IFCDPs after a mean observation period of 5.2 years
(range: 1-12 years). Secondary outcomes were the assessment
of the patient satisfaction and the effect of risk factors on the
incidence of the most common technical complications.
Materials and methods
This study’s protocol was approved by the Tufts Health
Sciences Campus Institutional Review Board (IRB approval #
11722). The recommendations for strengthening the reporting
of observational studies in epidemiology (STROBE) were
followed. All patients who had electronic records at the Depart-
ment of Postgraduate Prosthodontics, Tufts University School
of Dental Medicine (TUSDM) and had been rehabilitated with
4 Journal of Prosthodontics 29 (2020) 3–11 
Papaspyridakos et al
IFCDPs between January 1, 2005 and December 30, 2015
were screened.20,21
Inclusion criteria for this study comprised of patients
18 years or older; edentulous patients who had received rough
surface dental implants; edentulous patients who had been
rehabilitated with ceramic and MR IFCDPs in at least one
dentulous jaw, with a minimum of 1 year under functional
loading. Exclusion criteria included patients with less than
1 year since the insertion of the definitive IFCDP; patients
with smooth (machined) surface implants; patients who do
not wish to sign the informed consent form; and pregnant
females. Patients that met the inclusion criteria were contacted
and invited to participate in a comprehensive clinical and
radiographic examination. All patients gave written informed
consent after being informed in detail about the objectives
of the investigation.20,21 The informed consent document was
written in accordance with the “Declaration of Helsinki”.
A single-visit comprehensive examination was performed
for all eligible patients that signed the informed consent and
accepted participating in the study. At the examination visit,
information was recorded for both biologic and prosthetic
parameters and the former are reported separately in a previous
publication.20 This visit consisted of a medical and dental
history review, intraoral photographs, radiographic and clinical
examination.20,21 In brief, the examination was carried out by
4 calibrated prosthodontists (PP, TBB, YJK, KER) and the
following parameters were assessed: presence/absence of a
IFCDP; location of edentulous jaw; number of replaced teeth
and number of abutments; location of implants and number of
prosthetic segments (if not 1-piece); prosthetic materials used
to fabricate the prosthesis; type of retention (cement or screw);
presence/absence of nightguard; presence/absence of bruxism;
type of opposing dentition. The radiographic examination
included digital panoramic and periapical radiographs of
each implant with the long-cone technique.20,21 The occlusal
examination comprised the assessment of occlusal scheme (as
either mutually protected occlusion with anterior guidance
or group function). The opposing dentition was categorized
according to the presence of naturally restored or unrestored
teeth, implant-supported prostheses, overdenture, complete
denture, or removable partial denture.
During the single-visit examination, the IFCDPs were
examined and assessed for encountered complications or
failures.20,21 Technical complications that had affected the
implant-supported prostheses were divided into minor and ma-
jor complications.20,21 Minor complications were considered
those that no treatment was needed or if chair side repair was
feasible, e.g. chipping that could be only polished. The fol-
lowing were considered minor technical complications: wear
of the prosthetic material; chipping of prosthetic material; loss
of screw access material; loosening of an abutment/occlusal
screw; and decementation (loss of retention of cement-retained
IFCDPs). Major complications were those that needed addi-
tional laboratory and/or components costs.20,21 The following
were considered major technical complications: fracture of
C 2019 by the American College of Prosthodontists
Papaspyridakos et al Technical Complications with Full-Arch Implant Prostheses

Table 1 Descriptive overview of patients, location and material of separated according to the type of material: Group 1 (G1) – ce-
IFCDP, and observation time ramic; Group 2 (G2) – metal-resin (MR) prostheses. The Cox
proportional hazard model was used for survival analysis, ad-
Patients 52
justing for a number of potential confounders, to evaluate the
Female/male 21/31 association between prosthesis survival and several risk factors
Maxilla/mandible 38/33 such as type of opposing occlusion, nightguard use, and pres-
Ceramic/metal-resin 55/16 ence of bruxism. Responses to patient satisfaction questions
Cemented/screw retained 36/35 were compared with Fisher’s exact test. p-Values less than
Implants inserted 457 0.05 were considered statistically significant. The statistical
Implants mean observation time 7.5 years software SAS 9.4 (SAS Institute Inc, Cary, NC) and Stata 13.1
Prostheses mean observation time 5.2 years (StataCorp LLC, College Station, TX) were used in the analysis.

prosthetic material; fracture of framework; fracture of an
abutment; fracture of an abutment/occlusal screw; fracture of
an implant.
After completion of the comprehensive examination, the
patients received a short questionnaire to evaluate their
treatment satisfaction. The questionnaire was composed of
5 yes or no questions regarding satisfaction with esthetics,
ability to chew, taste, speech, and general satisfaction.
For porcelain chipping and fracture, the California Dental
Association rating system22 for quality was used to charac-
terize the ceramic failures as either acceptable (surface is
deficient but can be polished) or unacceptable (surface is
fractured and restoration must be repaired or replaced). For
simplicity, the previous descriptions were replaced by the terms
porcelain chipping (minor complication) and porcelain fracture
(major complication), respectively.8,11,21 Prosthesis survival
was defined as prosthesis remaining in situ with or without
modifications during the entire observation time.7,11,12,20,21
Prosthesis failure was defined as an event leading to the loss of
the prosthesis, the need to renew the entire implant-supported
prosthesis (retread), multiple repeated fractures of the implant-
supported prosthesis that affect function and esthetics, and
the explanation/loss of implants leading to the loss of the
implant-supported prosthesis.1,8,11,12,20,21
Descriptive statistics for patient follow-up time and patient
satisfaction were calculated as was the cumulative incidence of
technical complications. The Kaplan-Meier survival analysis
was used for assessment of prosthesis survival. Two timelines
were created: at 5 years and at 10 years. The definitive prosthe-
sis insertion was the baseline time. The prostheses were further
Results
Out of 90 eligible patients rehabilitated with 126 IFCDPs,
a total of 52 patients (average age of 65.5-year-old; ranging
from 39 to 88 years old) with 71 IFCDPs were included in
this study. The convenience sample consisted of 21 females
(average age of 64.6-year-old) and 31 male patients (average
age of 66.1-year-old) (Table 1). These 52 patients had received
457 moderately rough surface dental implants (Nobel Biocare,
Straumann, Biomet 3i). The mean follow-up time for the im-
plants was 7.5 years, ranging from 2.7 years to 13 years. A total
of 71 IFCDPs were evaluated; 38 in the maxilla and 33 in the
mandible (19 edentulous maxillae, 14 edentulous mandibles,
19 both). Out of the 71 IFCDPs, 55 were ceramic and 16
were MR (Group 2). With respect to the type of retention, 36
IFCDPs were cement-retained and 35 were screw-retained.
The opposing dentition was 40 IFCDPs, 16 mixed dentitions,
6 natural dentitions, 5 overdentures and 4 complete dentures.
In regards to the occlusal scheme, 58 arches had anterior
guidance (canine guidance), 12 group function, and 1 balanced
occlusion. The mean follow-up time was 5.2 years.
The 5- and 10-year prosthesis failure rate was 2.0% (95%
CI: 0.3-13.1%) and 18.7% (95% CI: 7.8-40.9%), respectively.
A total of 6 IFCDPs were lost out of 71 in total. One cement-
retained ceramic IFCDP was lost in Group 1 after 11 years
under function due to implant failures, while 5 MR IFCDPs
failed in Group 2 (three as a consequence of multiple fractures
and two because of failure of the corresponding supporting
implant) (Table 2). For Group 1 (ceramic), the 5- and 10-year
prosthesis failure rate was 0% for 55 IFCDPs. One prosthesis
failed after 11 years in function. For Group 2 (MR), the 5-year

Table 2 Overview of failures of the IFCDPs

Number of
implants
Patient Material of supporting Prosthesis Prosthesis
number Gender Arch IFCDP prosthesis delivery date Date failure noted follow-up (years) Reason

4 M Mx PFM 6 Jan, 2005 Jan, 2016 11 years Implant failure

19 F Md MR 6 April, 2010 Feb, 2016 5.8 years Implant failure
21 M Mx MR 5 April, 2010 July, 2016 6.2 years Multiple fractures
21 M Md MR 6 Dec, 2008 July, 2016 7.6 years Multiple fractures
28 M Md MR 6 Feb, 2008 June, 2016 8.3 years Implant failure
40 M Md MR 6 July, 2013 July, 2016 3 years Multiple fractures

M = male, F = female, Mx = maxilla, Md = mandible, PFM = porcelain fused to metal, MR = metal-resin.

Journal of Prosthodontics 29 (2020) 3–11 

C 2019 by the American College of Prosthodontists 5
Technical Complications with Full-Arch Implant Prostheses
Figure 1 Kaplan-Meier curve for prosthesis survival.
Figure 2 Kaplan-Meier curve for prosthesis survival between Group 1
(ceramic) and Group 2 (metal-resin).
prosthesis failure rate was 7.1% (95% CI: 1.0-40.9%) and
10-year was 58.2% (95% CI: 28.5-89.6%) for 16 metal-resin
IFCDPs. Out of 457 in total, only 6 implants failed during the
follow-up time of 1-12 years yielding a 10-year implant failure
rate of 3.0% (95% CI: 1.2-4.7%).
Kaplan-Meier survival curve analysis was carried out with
the prosthesis insertion as baseline (Fig 1). Additionally,
Kaplan-Meier survival curve analysis was done for both
Groups 1 and 2 separately (Fig 2), so as to show the prostheses
distribution over time.
A total of 274 technical complications were registered, af-
fecting 57 IFCDPs (80.3% or n = 57/71), with an average of 4.8
complications per prosthesis (minimum of 1, maximum of 21)
(Table 3). Consequently, 14 prostheses were free of complica-
tions (19.7% or n = 14/71). The cumulative rates for “prosthesis
free of complications” at 5- and 10-years were 58.28% (95%
CI: 45.3-69.2%) and 8.2% (95% CI: 2.8-17.4%), respectively.
Technical complications were further divided into minor and
major. Minor complications happened in 35 prostheses (49.3%
or n = 35/71) 185 times, with an average of 5.3 complications
per prosthesis (minimum of 1, maximum of 10). Thirty-six
prostheses (50.7% or n = 36/71) were free of minor com-
plications. The cumulative rates for “prosthesis free of minor
6 Journal of Prosthodontics 29 (2020) 3–11 
Papaspyridakos et al
complications” at 5- and 10-years were 60.5% (95% CI: 47.2-
71.3%) and 8.9% (95% CI: 2.9-18.0%), respectively. The most
frequently observed minor technical complication was wear of
the prosthetic material (9.8%), as described in Tables 3 and 4.
Major technical complications occurred in 22 prostheses
(31% or n = 22/71) 89 times, with an average of 4 com-
plications per prosthesis (minimum of 1, maximum of 15).
Prostheses with more than 5 major complications failed due to
multiple fractures of the prosthetic material (n = 3/71).
Forty-nine prostheses (69% or n = 49/71) were free of major
technical complications. The cumulative rate for “prosthesis
free of major technical complications” at 5-year was 85.5%
(95% CI: 73.0-92.5%) and at 10-year was 30.1% (95% CI:
12.0-50.6%). The most frequently observed major technical
complication was fracture of the prosthetic material (1.9%), as
shown in Table 3.
From 1 to 12 years of prosthesis follow-up, 42 IFCDPs
(n = 42/55) in Group 1 (ceramic) and 15 IFCDPs (n = 15/16)
in Group 2 (MR) showed at least one technical complication,
resulting in 76.4% complication rate in Group 1 and 93.7% in
Group 2, respectively. A total of 177 technical complications
were registered in Group 1, however, since decementation
could only happen in a cement-retained type of IFCDPs
and no comparison would be possible with Group 2, this
complication was excluded from the comparison. So, a total of
154 complications were registered in Group 1, with an average
of 3.7 complications per prosthesis (minimum of 1, maximum
of 15), as showed in Table 4.
The most frequent complication was wear of the prosthetic
material (7.3%), affecting 34.6% of the IFCDPs (n = 19/55).
While in Group 2, a total of 97 complications were encountered,
with an average of 6.5 complications per prosthesis (minimum
of 1, maximum of 21). The most frequently observed com-
plication was also wear of the prosthetic material, however
with a statistically significant higher rate (19.4%) (p < 0.05),
affecting 81.3% of the IFCDPs (n = 13/16). The risk of wear
of the prosthetic material was 0.4 lower in Group 1 compared
with Group 2 (Hazard Ratio 95% CI: 0.2-0.9) (Table 5).
A total of 121 minor complications were registered in Group
1, affecting 38.2% of the IFCDPs (n = 21/55), with an average
of 5.8 complications per IFCDP (minimum of 1, maximum of
9). A total of 41 minor complications were observed in Group 2,
affecting 87.5% of the IFCDPs (n = 14/16), with an average of
2.9 complications per IFCDP (minimum of 1, maximum of 10).
The minor complication most frequently registered in Group
1 was wear of the prosthetic material (7.3%), followed by
porcelain chipping (2.5%), and loss of screw access filing ma-
terial (1.3%). While in Group 2 wear of the prosthetic material
(19.4%) was the most frequently observed minor complication,
followed by loss of screw access filing material (4.6%),
and loosening of a screw (0.6%) (Table 4). Chipping of the
prosthetic material was significantly more frequently observed
in Group 1 (2.5%) compared with Group 2 (0.3%) (p < 0.05).
The risk of chipping was 4.7 times higher in Group 1 compared
with Group 2 (hazard ratio 95% CI: 1.12-19.77%) (Table 5).
In Group 1, a total of 33 major technical complications
affecting 21.8% of the IFCDPs (n = 12/55), with an average
of 2.7 complications per prosthesis (minimum of 1, maximum
of 7) were observed. While in Group 2, 56 major complications
C 2019 by the American College of Prosthodontists
 Table 3 Overview of technical complications in IFCDPs

Total no. of Complication Estimated

prostheses, No. of prostheses rate (%) Annual Estimated 5-year 10-year
teeth, implants in with No. of Complication (Prostheses Exposure complication complication rate complication rate
the study complications complications percentage level) time (y) rates (95%CI)∗ (95% CI) (95% CI)
Papaspyridakos et al

Minor Complications 35 185 67.5 77.5

Wear of the prosthetic material 71 prostheses 32 32 11.7 46.5 328 9.8 (6.8-13.6) 49.0 (36.2-68.4) 98.0 (70.3-133.6)
Decementation (loss of retention) 36 prostheses 10 23 8.4 27.8 340 2.9 (1.6-5.5) 14.7 (8.0-27.5) 29.4 (1.1-55.0)
Loss of screw access filing 214 implants 14 30 10.9 42.9 1112 2.7 (1.9-3.8) 13.5 (10.7-17.9) 27.0 (21.2-36.1)
Chipping of prosthetic material 869 teeth 31 87 31.7 43.7 4411 2.0 (1.6-2.4) 10.0 (9.1-11.2) 20.0 (18.2-22.9)

Journal of Prosthodontics 29 (2020) 3–11 

Loosening of a screw 457 implants 5 10 3.6 7.0 2366 0.4 (0.2-0.7) 2.0 (1.1-3.3) 4.0 (3.1-5.9)
Loosening of an abutment screw 457 implants 2 3 1.1 2.8 2376 0.1 (0.03-0.3) 0.5 (0.2-1.4) 1.0 (0.4-2.6)
Major Complications 22 89 32.5 31
Fracture of the prosthetic material 869 teeth 20 82 29.9 28.2 4418 1.9 (1.5-2.3) 9.5 (8.6-11.1) 19.0 (16.7-21.6)
Fracture of a screw 457 implants 2 6 2.2 2.8 2371 0.3 (0.1-0.5) 1.5 (0.6-2.4) 3.0 (1.7-4.6)
Fracture of framework 71 prostheses 1 1 0.4 1.4 368 0.3 (0.01-1.3) 1.5 (0.1-6.3) 3.0 (0.2-11.6)
Fracture of an abutment 457 implants 0 0 0 0 0 0 0 0
Fracture of an implant 457 implants 0 0 0 0 0 0 0 0
Total 57 274 100 80.3

CI = confidence intervals.

Table 4 Technical complications in IFCDPs—comparison between the groups

C 2019 by the American College of Prosthodontists

Group 1 Group 2

Total no. of
Total no. of No. of Compli- prostheses, No. of Compli- Expo-
prostheses, teeth prosth. cation Actual annual teeth and prosth. cation sure Actual annual
and implants in with com- No. of perce- Exposure complication implants in with com- No. of perce- time complication rate
Group 1 plications events ntage time (year) rate (95% CI) Group 2 plications events ntage (year) (95% CI)

Minor Complications 21 121 78.6 14 41 42.3

Wear of the prosthetic material 55 prostheses 19 19 12.3 261 7.3 (4.5-11.2) 16 prostheses 13 13 13.4 67 19.4 (10.8-32.4)
Chipping of prosthetic material 673 teeth 29 84 54.5 3395 2.5 (2.0-3.0) 196 teeth 2 3 3.1 1021 0.3 (0.1-0.8)
Loss of screw access filing 116 implants 6 8 5.2 603 1.3 (0.6-2.5) 98 implants 8 22 22.7 482 4.6 (2.9-6.8)
Loosening of a screw 359 implants 4 7 4.5 1860 0.4 (0.2-0.7) 98 implants 1 3 3.1 507 0.6 (0.2-1.6)
Loosening of an abutment screw 359 implants 2 3 1.9 1866 0.2 (0.04-0.4) 98 implants 0 0 0 510 0
Major Complications 12 33 21.4 10 56 57.7
Fracture of prosthetic material 673 teeth 10 26 16.9 3471 0.7 (0.5-1.1) 196 teeth 10 56 57.7 948 5.9 (4.5-7.6)
Fracture of framework 55 prostheses 1 1 0.6 285 0.4 (0.02-1.7) 16 prostheses 0 0 0 83 0
Fracture of a screw 359 implants 2 6 3.9 1869 0.3 (0.1-0.7) 98 implants 0 0 0 510 0
Fracture of an abutment 359 implants 0 0 0 1869 0 98 implants 0 0 0 510 0
Fracture of an implant 359 implants 0 0 0 1869 0 98 implants 0 0 0 510 0
Total 42 154 100 15 97 100

7
Technical Complications with Full-Arch Implant Prostheses

CI = confidence intervals.
Technical Complications with Full-Arch Implant Prostheses Papaspyridakos et al

Table 5 Risk factors—hazard ratio 95% confidence interval

Porcelain vs metal-resin∗ Nightguard Bruxism

Minor complications
Wear of the prosthetic material 0.4(0.2-0.9)∗∗ 0.9(0.2-3.7) 0.6(0.2-1.9)
Chipping of prosthetic material 4.7(1.12-19.77)∗∗ 4.4(1.1-17.8)∗∗ 0.1(0.03-0.5)∗∗
Loss of screw access filing 0.8(0.03-0.9)∗∗ 0.5(0.02-10.4) 5.9(0.7-47.1)
Loosening of an abutment NA NA NA
Loosening of a screw 1.7(0.01-68.23) NA NA
Loss of retention NA NA NA
Major complications
Fracture of prosthetic material 0.2(0.04-0.95)∗∗ 0.15(0.02-1.05) 1.07(0.20-5.67)
Fracture of framework NA NA NA
Fracture of an abutment NA NA NA
Fracture of a screw NA NA NA
Fracture of an implant NA NA NA
*
Adjusted for night guard use, bruxism, and opposing dentition.
p value <0.05.
**

NA = not applicable.

were registered, affecting 62.5% of the IFCDPs (n = 10/16),
with an average of 5.6 complications per prosthesis (minimum
of 1, maximum of 15). As Table 4 shows, the most frequently
observed major technical complication was fracture of the pros-
thetic material in both groups (Group 1 = 0.7%, Group 2 =
5.9%), and it was also the only major complication observed in
Group 2 (metal-resin), showing a statistically significant differ-
ence between the groups (p < 0.05), where the risk of fracture
was 0.2 lower in Group 1 compared with Group 2 (Hazard Ratio
95% CI: 0.04-0.95). At a prosthesis level, statistically signifi-
cant fewer major technical complications occurred in Group 1
(21.8%) than in Group 2 (62.5%) (p = 0.004).
More than 94% of the patients, in general, were satisfied
with their IFCDPs. The ability to taste the food was the
category that showed the highest number of patients satisfied
(98.1%). On the other hand, the ability to chew showed the
lowest number (88.5%) (Table 6). The statistical comparison
of patient satisfaction between the two groups showed that
more patients were satisfied with their ability to chew in Group
1 (95.1%) than in Group 2 (63.6%) (p = 0.01). Also, more
patients were satisfied in general with their treatment in Group
1 (100%) than in Group 2 (72.7%) (p = 0.007).
Porcelain veneering material, presence of bruxism, and
absence of a nightguard were associated with increased risk for
chipping of the prosthetic material of the IFCDPs (p < 0.05).
The risk of chipping was 4.6 times higher in the ceramic type
of IFCDPs compared with the MR type of prosthesis (Hazard
Table 6 Patient satisfaction
General Group 1 (%)
Esthetics 92.3 95.1
Ability to chew 88.5 95.1∗
Ability to taste 98.1 100
Ability to speak 92.3 95.1
General 94.2 100+
*
Statistically significant different (p = 0.01).
+
Statistically significant different (p = 0.007).
Ratio 95% CI: 1.12-19.77). The risk of chipping was 4.4 higher
in patients, who did not use a nightguard compared with those
who used it (hazard ratio 95% CI: 1.1-17.8). Additionally,
the risk of this complication was lower in patients diagnosed
without bruxism in relation to those who were diagnosed with
bruxism (Hazard Ratio 95% CI: 0.03-0.5) (Table 5).
Discussion
The objective of this retrospective study was to report the tech-
nical complication and prosthesis survival rates with IFCDPs
for edentulous patients after mean exposure time of 5.2 years
(range: 1-12 years). The findings of this study show a high
cumulative implant and prosthesis survival rates of 98.7% and
91.7% after a mean observation period of 5.2 years (range 1-12
years), respectively. Out of 71 IFCDPs (supported by 457 rough
surface) 6 failed, yielding a cumulative 10-year survival rate of
91.7%. The IFCDP survival is directly related to implant sur-
vival. Out of the 6 IFCDP failures, 3 were attributed to late im-
plant failures in 3 patients (2 implant failures each) and affected
the IFCDP survival. These 3 patients had to be switched to over-
dentures from the previously IFCDPs. The remaining 3 IFCDP
failures were observed in Group 2 (metal-resin) and were due
to technical complications and prosthetic material failure.
The implant and prosthesis survival rates reported in this
study are in accordance with the findings of systematic
reviews that demonstrated that treatment with maxillary
and mandibular IFCDPs yields high implant and prosthesis
survival rates, namely more than 96% after 10 years.8,23 The
Group 2 (%) slightly lower prosthesis survival rate of 91.6% in this study
was mainly due to late implant failures after 5 years, which
81.8
63.6∗
necessitated the removal of the involved IFCDPs and patients
90.9
to be switched to overdentures. The 3 IFCDPs that had to be
81.8 replaced with overdentures were structurally sound.
72.7+ In this study, out of the 6 IFCDP failures (6/71), 3 were
attributed to late implant failures in 3 patients (2 implant
failures each) and affected the IFCDP survival. As mentioned
above, these 3 patients had to be switched to overdentures

8 Journal of Prosthodontics 29 (2020) 3–11 

C 2019 by the American College of Prosthodontists
Papaspyridakos et al
from the previously made IFCDPs. The remaining implants
in these 3 patients were sound and were used to support the
overdentures. The prosthesis design may have had an adverse
effect on cleansability and implant survival for 1 patient (2
implant failures), since a ridge-lap, cement-retained IFCDP
had been inserted. Ridge laps are contra-indicated, especially
when combined with cement retention. The inappropriate pros-
thetic design may potentially be one of the reasons for these
2 implant failures.20 The remaining 3 IFCDP failures were
observed in the MR group (Group 2) and were due to technical
complications and prosthetic material failure. These findings
are similar to the ones reported previously in literature, where
out of 108 MR IFCDPs 7 were converted into implant over-
dentures and 2 were converted into complete dentures because
of late implant failures.10 In regards to biologic complications
and peri-implantitis, a 5-year implant-based peri-implantitis
rate of 10% (95% CI: 8.9-11.5) and a 10-year implant-based
rate of 20% (95% CI: 16.9-24.9) was reported in a separate
publication on the same patient cohort.20 Overall, 10.1% of the
457 implants supporting the 71 IFCDPs exhibited signs of peri-
implantitis.20 Additionally, the 5- and 10-year cumulative rates
for “prostheses free of biologic complications” were 52.5%
(95% CI: 39.9-63.7%) and 8.1% (95% CI: 2.8-17.2%), respec-
tively. This highlights the importance of appropriate prosthetic
design for cleansability and regular maintenance through
recalls.20,21
In regards to complications, the most frequent minor tech-
nical complication was wear of the prosthetic material (9.8),
while the most frequent major technical complication was
fracture of the prosthetic material (1.9%). These findings are
in accordance with the complication rates reported in the lit-
erature. All prosthetic materials are subject to time-dependent
wear and a variety of factors are affecting it. Papaspyridakos
et al10 reported that the most frequent technical complication
reported with metal-resin IFCDPs was prosthetic material
chipping/fracture. Technical complications after the definitive
prosthesis placement may result in an increased number of
repairs and maintenance sessions.10 MR IFCDPs exhibited
more wear of the prosthetic material than the ceramic type
IFCDPs (7.3%), yielding a statistically significant difference
associated with the percentage of wear between the 2 groups.
This is in accordance with what is reported in the literature
regarding acrylic teeth and wear. Another study assessed 205
edentulous arches restored with MR IFCDPs and reported that
the replacement of denture teeth (retread) occurred after an av-
erage of 7.8 years.14 It has to be mentioned that there are more
variables that may affect prosthesis integrity and survival such
as opposing dentition, occlusal schemes, and anterior-posterior
implant spread.23 In the present investigation, these data were
recorded but not further analyzed. Rather, the effect of bruxism,
the absence of a nightguard and porcelain veneering material
were analyzed and eventually associated with increased risk
for chipping of the prosthetic material of the IFCDPs.
To the authors’ knowledge, this is the first study that attempts
to report separately and compare complications encountered
between these 2 groups (ceramic type vs MR). However, the
number of IFCDPs in Group 1 (55) was 3.5 times more than
Group 2 (16), and this represents one of the limitations of this
Journal of Prosthodontics 29 (2020) 3–11 
C 2019 by the American College of Prosthodontists
Technical Complications with Full-Arch Implant Prostheses
study since the size of the two groups was disproportionate,
and the comparative analysis should be read with caution. The
preponderance of literature reporting on longitudinal follow-
ups includes MR IFCDPs.3,9 The longitudinal effectiveness of
the MR IFCDPs against maxillary complete dentures has been
demonstrated in the literature, with considerably high rates of
technical complications like wear and chipping encountered
as a result of material fatigue and stress.14 Studies have also
reported on the incidence of complications with ceramic type
IFCDPs.6,19,25-30 While no studies have been identified directly
comparing intra-group ceramic IFCDPs to MR IFCDPs, it must
be mentioned that there is paucity of reports on complications
with ceramic IFCDPs for edentulous jaws with observation
periods of at least 5 years conversely with the MR design.8
This study reports data on patient-centered outcomes. The
patients’ high satisfaction rate in this study demonstrates
that treating the edentulous predicament with osseointegrated
implants is an effective treatment modality. Satisfaction was
greater among patients restored with ceramic type versus
MR IFCDPs and it can be hypothesized that the wear of the
prosthetic material especially observed in the MR group or
the reduced proprioception in completely edentulous patients
could have played a role.6,14,30
Strong points of this retrospective study include the long-
term follow-up of up to 12 years and the relatively large
cohort of edentulous patients, whereas limitations pertain to
the retrospective design. The retrospective design is inherently
associated with sampling bias because it depends on acquired
data from files and records that have been registered by various
clinicians. However, even though retrospective studies rank
below RCTs and prospective clinical trials in the hierarchy of
evidence, long-term retrospective studies with mean follow-ups
of >5 years can offer significant clinical information.3 Not
being able to remove the IFCDPs at the examination visit is an
additional limitation of this study. Additionally, it was not pos-
sible to record the preoperative condition of the patients prior to
implant placement, which represents an additional limitation.
The clinical implications of the present retrospective study
pertain to the high implant survival rates achieved during full
arch rehabilitation with IFCDPs after a long-term follow-up.
However, only 58.28% of the IFCDPs were free of complica-
tions at 5-years and this indicates a very high maintenance load
for either form of prosthesis at face value. At the 5-year land-
mark and when broken down to minor and major complications,
cumulative rate for “prosthesis free of minor complications”
was 60.5% (95% CI: 47.2-71.3%) and cumulative rate for
“prosthesis free of major technical complications” at 5-year
was 85.5% (95% CI: 73.0-92.5%). This might be manageable in
an institutional setting but could be a high financial liability in a
private practice setting. More studies are necessary to ascertain
the financial burden of prosthetic maintenance of full-arch
implant rehabilitation. The patients should also be informed
that they have to adhere to frequent maintenance that also
carries a cost. While 40 out of the 71 IFCDPS were followed
for more than 5 years, significantly more wear and prosthesis
failures were found in the MR group. The initial lower cost
of metal-resin IFCDP may be outweighed by the significantly
more maintenance burden in the longitudinal follow-up.
9
Technical Complications with Full-Arch Implant Prostheses
Conclusions
Under the limitations of this retrospective study, the most fre-
quent minor technical complication was wear of the prosthetic
material, whereas the most frequent major complication was
fracture of the prosthetic material. Significantly more wear
was observed in the MR IFCDPs compared with the ceramic
type IFCDPs. The porcelain material, the presence of bruxism,
and the absence of nightguard were associated with increased
risk for chipping of the prosthetic material of the IFCDPs.
Significantly more patients were satisfied in general with their
treatment with ceramic IFCDPs than with MR IFCDPs. The
cumulative rates for “prosthesis free of minor complications”
at 5- and 10-years were 60.5% (95% CI: 47.2-71.3%) and
8.9% (95% CI: 2.9-18.0%), respectively. The cumulative rates
for “prosthesis free of major technical complications” at 5- and
10-years were 85.5% (95% CI: 73.0-92.5%) and 30.1% (95%
CI: 12.0-50.6%), respectively.
Acknowledgments
This study was supported by the Department of Prosthodon-
tics at Tufts University School of Dental Medicine (IRB
#11722/2015) and the Brazilian National Council for Scientific
and Technological Development (CNPq 235084/2014-0). The
authors would like to express their gratitude to Dr Fulvio
Fratipietro and Dr Catherine DeFuria for their assistance in the
clinical and radiographic examination.
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